Postnatal Contraception - Depo-Provera¢® (Medroxyprogesterone 150mg IM) ... Postnatal contraception

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  • D R J B R I D I E M E E

    B A M B B S D R A N Z C O G F R A C G P

    1 2 T H A U G U S T 2 0 1 7

    M C H N V I C C O N F E R E N C E

    Postnatal Contraception

  • A quick survey

  • Mothers group survey

  • The reality

    hurrahforgin.com

  • Get a foot in the door!

  • Structure of talk

    1. Background unplanned pregnancy and fertility

    2. Contraceptive options

    3. Emergency contraception

  • lets talk about sex

  • RANZCOG recommendations

    Faculty of Sexual and Reproductive Healthcare, 2017

  • RANZCOG recommendations (2)

    Faculty of Sexual and Reproductive Healthcare, 2017

  • RANZCOG recommendations (3)

    Faculty of Sexual and Reproductive Healthcare, 2017

  • Patient centered

    Have you considered what contraception you would like? We recommend having a plan in place early

    Implanon and IUD are the most reliable options but many have not considered them, what are your thoughts?

    Have you thought about if and when you might like to pregnant again?

    Are you aware of how long women are recommended to wait to get pregnant again? Does this fit with your family planning?

    Avoid should / need / must language, new mums are very sensitive!

  • 1. Background

    Unplanned pregnancy

    Dispelling fertility myths

    Birth-to-pregnancy interval recommendations

    Patient factors to consider

  • Unplanned pregnancies

    pregnancies unplanned UP to pregnancies aborted

    84.6% pregnancies unplanned (Coombe 2016), 73.4% while using contraception COCP 39.1% Condoms 29.4% None 26.6% Withdrawal 18.5%

    Limited estimates of postpartum unplanned pregnancy prevalence (Rowe 2016) 15-17% of 2nd, 3rd and 4th pregnancies unplanned 9% abortions due to having a young baby

  • Fertility

    Fertility 85% normal couples pregnancy within 12 months

    Fercundity Ability to achieve pregnancy in one menstrual cycle

    Normal couple 20-25% for first 3 months, 15% next 9 months

    Postpartum fertility Exclusive breastfeeding unlikely to ovulate < 6 weeks

    Not breastfeeding can ovulate from 3-4 weeks

  • Dispelling fertility myths

    If I needed IVF for this pregnancy I dont need contraception

    If I have PCOS I dont need contraception

    Im too old to need contraception

    I cant get pregnant if Im breastfeeding

    My friend took [contraceptive] but it ruined her periods / made her infertile etc

  • How soon is too soon to get pregnant again?

    World Health Organization (WHO) recommends 24 months for birth-to-pregnancy interval

  • WHO birth-to-pregnancy interval

    6-12 months risk maternal mortality/morbidity

    18 months risk infant, neonatal, perinatal mortality

    risk low birth weight, small for gestational age, preterm

    27 months minimal adverse maternal, perinatal and infant outcomes

    18-27 months - may be residual risk

    VBAC < 16 months : risk uterine rupture

  • Faculty of Sexual and Reproductive Healthcare birth-to-pregnancy interval

    RANZCOG Statements and Guidelines

    (Royal Australian and New Zealand College of Obstetrics and Gynaecology)

  • Medical factors birth to pregnancy interval

    Caesarean

    Pelvic floor and perineum recovery

    Medical conditions / medications

    Mental health

    Social / financial

  • 2. Contraception Options

    Breast feeding

    Natural planning

    Barrier method

    Hormonal

    LARCs

    (long acting reversible contraception) Contraceptive insert (Implanon)

    Intrauterine device (IUD - Mirena, Copper-T)

    Sterilisation

  • Patient Factors - choosing contraception

    Efficacy - importance of fertility control

    Breastfeeding

    Acceptability Personal experience / preference

    Knowledge vs misinformation

    Personal values (cultural, religious, body view)

    Cost, convenience, accessibility

    Patient safety Medical conditions (physical conditions, chronic illness,

    mental health, medications)

    Social situation (age, vulnerability, access)

  • Explaining efficacy to patients

  • Efficacy per 100 woman years

    Efficacy per sexual encounter

    http://familyplanningallianceaustralia.org.au/wp-content/uploads/2015/08/Contraceptive-Counselling-Card.pdf

  • Breastfeeding lactational amenorrhoea method

    Nursing prolactin hypothalamic suppression ovulation 50% begin to ovulate between 6-12 months

    Efficacy : 98% (perfect use) Exclusively and regularly breastfed (nil formula / solids)

    4 hour intervals during day, 6 hour intervals overnight

    No menses

    Baby < 6 months old

    Efficacy : 45-85% (actual use) Will still need a contraception plan from 6 months

  • Coitus interruptus

    Efficacy: 78% (typical use)

    96% (perfect use)

    Pros : pregnancy

    Cons : pregnancy

  • Natural Planning

    Efficacy : 76% (typical) 99.5% (perfect)

    Types: Symptom based : Cervical secretions, basal body temperature

    Calendar based : Calendar Rhythm or Standard Days Method Breastfeeding

    Cycle dependent. Can use postpartum : Calendar rhythm method once had 3 cycles and regular.

    Standard Days Method after 4 cycles.

    Pros : no cost

    Cons : low efficacy. Requires abstinence / barrier contraception until cycles regular

  • Natural Planning cont.

    Calendar Rhythm Method : shortest cycle 19 longest cycle 10 (eg 30-36 day cycle,

    would be fertile days 12-25)

    Standard Days Method : avoid intercourse on days 8-19 if cycle is 26-32 days long

  • Barrier Methods

    Condoms Efficacy : 82% (typical use) - 98% (perfect use) per encounter

    Pros : STI protection, non-hormonal

    Cons : high failure rate

    Diaphragm Efficacy : 88% (typical use) - 94% (perfect use) per encounter

    > 6 weeks postpartum (uterine involution complete)

    Cons : Needs to be fitted, higher risk failure in parous women

  • Hormonal Options progestin only

    Minipill (levonorgestrel) Efficacy : 91% (typical use) - 99.7% (perfect use)

    Changes cervical mucus, does not reliably prevent ovulation

    Safe for breastfeeding

    Side effects : irregular bleeding, amenhorrea.

    Less common side effects : acne, breast pain, abdominal pain, dizziness, mood changes

    Cost : $13.50 / 4 months

    Pros : cheap, acceptable

    Cons : narrow therapeutic window (2-3 hours)

  • Hormonal Options progestin only

    Depo-Provera (Medroxyprogesterone 150mg IM) Efficacy : 94% (typical use) - 99.8% (perfect use)

    Prevents ovulation

    Safe in breastfeeding

    Side effects : irregular bleeding, amenorrhoea (50% by 12 months), delayed fertility upon cessation (up to 18 months)

    Less common side effects : weight gain, acne, mood changes, depression, increased risk of bone loss (with prolonged use)

    Cost : $25 / 3 months

    Pros : cheap, can improve menorrhagia / dysmenorrhoea etc

    Cons : 12 weekly injection, not appropriate in age extremes due to bone loss (adolescents, > 45 yo)

  • World Health Organization

    Page 105

  • Initiating postpartum progestin-only

    WHO p. 157

  • Hormonal options - combined

    Combined oral contraceptive pill (COCP) Efficacy : 91% (typical use) - 99.7% (perfect use)

    > 3-6 weeks postpartum (VTE risk)

    Common side effects : headache, nausea, breakthrough bleeding + progestin side effects

    Cost : depends on brand, (Levlen $13 / 4 months)

    Pros : high acceptability, cheap, reduce ovarian & endometrial cancer, improve gynaec symptoms

    Cons : contraindicated in smokers > 35 yo, VTE risk etc

    Extended regimens same efficacy contraception with reduced hormonal withdrawal symptoms and reduced menses

    Continuous pack use, Yaz Flex, Seasonique

  • Hormonal Options - combined

    Nuva ring Efficacy : 91% (typical use) - 99.7% (perfect use)

    > 6 weeks postpartum (VTE RISK)

    Cost : $33 / month

    Cons : expensive, acceptability

    Family Planning NSW

  • Timing of combined hormonal contraception

    Faculty of Sexual and Reproductive Healthcare, 2017

  • COCP & breastfeeding debate

    YES NO MAYBE

    VS VS

    RANZCOG Therapeutic Guidelines WHO (O&G) (GP) (the world)

  • YES - breastfeeding & combined hormonal

    Faculty of Sexual and Reproductive Healthcare, 2017

  • NO - breastfeeding & combined hormonal

  • MAYBE - breastfeeding & combined hormonal

    WHO pg 113

  • Non-breastfeeding & COCP

    WHO pg 113

    COCP Ring

  • Combined oral contraceptives

    MDBriefCase Australia 2017

  • LARCs (long acting reversible contraception)

    Contraceptive insert (Implanon)

    IUD (Mirena, Copper-T)

    Most reliable contraceptives for typical use

    Low uptake in Australia despite relative affordability compared to other countries

    LARCs used by < 10% Australian women Largely attributed to lack of patient awareness and medical

    access

  • Implanon (etonogestrel)